Laryngopharyngeal Reflux Disease (LPR)

Acid reflux may be a primary cause of or a contributing factor to voice problems. Many people have heard of acid reflux disease. When the refluxing of stomach acid primarily affects the esophagus, it is termed gastroesophageal reflux disease (GERD). When the refluxing affects primarily the voice production system - the larynx and pharynx - it is called laryngopharyngeal reflux disease (LPR). It may also be called "reflux laryngitis".

Laryngopharyngeal Reflux: LPR has caused inflammation (redness and swelling) of the back of the larynx. The vocal fold mucosa is irritated and copious thick secretions cover the vocal folds. This causes discomfort and irregular mucosal wave vibration, leading to voice changes.

When normal, healthy individuals eat or drink, swallowing propels food and liquid from the back of the mouth down into the esophagus, the tube connecting the mouth to the stomach. Two esophageal sphincters, or valves, open and close in such a way as to promote passage of food into the stomach and prevent backflow.

GERD, or "classic" reflux, occurs when the acid contents move from the stomach backwards up the esophagus, due either to improper functioning of one or both sphincters (which can be aggravated by a condition known as "hiatal hernia") or due to muscular spasms of the esophagus.

LPR occurs when refluxed stomach contents reach all the way up into the throat. Almost everyone experiences reflux occasionally. When acid reflux occurs often, however, the larynx can become irritated, because the larynx and back of the throat do not have the same type of lining as the esophagus to protect from acidic fluids. Sometimes, if the LPR is severe enough, it can cause a non-cancerous lesion (growth) on the back of the vocal fold, called a granuloma.

Symptoms of LPR can include: a choking sensation, sometimes severe enough to wake a person up at night; sore throat; voice changes; a sensation of something caught in the throat; frequent coughing and throat clearing; and a sour or bitter taste in the mouth, especially upon rising in the morning. The "classic" symptoms of heartburn, burping or chest pressure are associated with GERD, but not necessarily with LPR.

Many patients with voice problems caused by LPR are not even aware that they have acid reflux problems. Because of the many bothersome symptoms of LPR, this condition can create habits which further contribute to the voice problem, such as constant throat-clearing or using excessive muscle tension when speaking.

LPR is treated primarily in two ways. Making some simple lifestyle, or behavioral changes can help prevent or decrease LPR and improve the voice. Take a look at our LPR Precautions Tips (PDF) for some helpful suggestions. In conjunction with lifestyle changes, medications can also be used to help control LPR. Behavioral changes should always accompany medication regimens to help the medication work most effectively. In many instances, it can take a few months of regular medication use before the LPR symptoms are significantly reduced.

There are many medications, some over-the-counter and some requiring a prescription. The amount of medication taken, and the time of day it is used, can significantly influence its effectiveness. If you think you have reflux laryngitis, see an otolaryngologist (ear, nose and throat physician) who is experienced in treating voice disorders.

A Gastroesophageal Reflux Disease that Affects the Voice

Your voice disorder may be due, in part, to the escape (reflux) of acid and other digestive fluids from the stomach into the esophagus (the tube connecting the stomach to the throat) and up onto the larynx (“voicebox”). Gastroesophageal reflux disease (GERD) can cause irritation and inflammation of the esophagus, resulting in heartburn type pain and burping. Laryngopharyngeal reflux (LPR), however, occurs when the acids move up and out the esophagus and deposits onto the larynx. This can cause inflammation, voice changes, and formation of contact ulcer or granuloma (noncancerous growths).

LPR is often a silent condition without the “classic” symptoms of GERD.

Symptoms of LPR may include chronic coughing, throat-clearing, sore throat, voice changes that are often worse in the morning upon rising, a persistent sensation of thick mucous in the throat, or waking frequently at night with a choking sensation. LPR is now recognized as a major contributing factor in voice disorders. This means that some voice disorders could be caused by reflux, and others fail to heal due to the chronic irritation of reflux.

A reflux control program is a medical regimen. You should discuss your condition and needs with your physician and rigorously follow your doctor's advice. Many of the following suggestions are commonly provided to patients by their physicians. These guidelines can help retain acid in the stomach and prevent it from escaping into the esophagus and larynx. All of the following suggestions require behavior modification and not every suggestion applies to every patient.

Discuss your condition with your physician before starting any type of reflux control regimen.

What You Eat May Affect Your Reflux

Alcohol, bananas, tomatoes, citrus fruits, dairy products, chocolate, cocoa, greasy foods, peppermint, coffee, tea, and all soft drinks that contain caffeine (colas) may aggravate reflux. Many of these have been shown to either decrease the effectiveness of the valve mechanism separating the esophagus and the stomach or trigger acid production. Many individuals find it best to eliminate all coffee and carbonated beverages. It should be remembered that not everyone reacts to these foods in the same way. Your condition will be uniquely individual.

When and How You Eat May Affect Your Reflux

Do not lie down for two hours after meals. Actually, standing or walking is better than sitting. Bedtime snacks of all types should be avoided. Food of any sort, including milk, will increase gastric secretion after you have gone to bed. This will cause more acid which could be refluxed. Try to schedule more meals with smaller portions, avoid filling the stomach to capacity. Do not overeat as overfilling the stomach promotes reflux of gastric contents.

Lose Weight: Many reflux problems are directly related to obesity, and so a weight loss program is important. Anything that puts extra pressure on your abdomen can aggravate reflux. This includes tight clothing and exercising immediately after eating.

Stop Smoking! In addition to causing cancer, smoking causes significant changes to the vocal fold tissues, resulting in voice problems. Smoking also decreases the effectiveness of the valve separating the stomach and the esophagus.

Elevate the Head of Your Bed: The head of your bed should be elevated with four-inch blocks. Do not sleep with multiple pillows under your head because this will increase the pressure in your abdomen and cause more reflux. Your bed should not be bent or jack-knifed but should be straight so that your entire body is sleeping on a tilt. This allows gravity to keep digestive juices in your stomach and prevents them from escaping into the lower esophagus. Do not sleep on your abdomen (face down) or on your right side, as these two positions could facilitate reflux of gastric contents.

Medications

No one should start, stop or change medications without first consulting a physician

Medications to Control Reflux

There are many good over the counter antacids that help to chemically neutralize stomach acid. These are fast acting and designed to treat or infrequent symptoms. These can have side effects, particularly for patients with certain conditions or individuals over the age of 60. Antacids can also mask other possible problems like esophageal ulcers. There are over the counter medications called H2 blockers that are about half the strength of their prescription version. These products relieve heartburn in many patients by reducing the production of stomach acids. This is accomplished by switching off certain receptors in the stomach, thereby helping control heartburn since there will be less acid produced. Newer prescription medications known as 'proton pump inhibitors'(PPI) appear to shut down the "pump" that secretes acid into the stomach. These medications are frequently used for patients who have not responded to other treatments.

When You Take Your Reflux Medication May Be Important

Some types of reflux medications are meant to be taken only when you experience symptoms. Other reflux control medications must be taken every day in order to be effective. Taking medication in the evening may be more effective than taking it in the morning. Research suggests that in some cases, it may take a number of weeks in order for the medication to have a beneficial effect upon your voice. Carefully discuss with your physician how often, and the time of day, you should take your medication.

Other Medications May Affect Your Reflux

Many people have been unknowingly aggravating their problems by taking large amounts of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), or one the hundreds of over the counter preparations which are aspirin-containing compounds. All anticholinergics (stomach relaxers, antispasmodic drugs) may also aggravate reflux.